90/M ? TB MENINGITIS with ?PTB

 case of 90 year old male came with complaints of

c/o cough since 15 days

SOB since 1 week 

Loss of appetite since 1 week 

Altered sensorium since 3 days 





 HOPI: 

Patient was apparently asymptomatic 15 days ago then he developed cough insidious onset initially dry later productive and scanty.white to yellow not blood stained more during night. SOB since 1 week insidious onset gradually progessive ,progressed to grade 4, no orthopnea, No PND.No h/o seasonal/diurnal variation.

Loss of appetite since 1 week. No h/o fever, vomiting,pain abdomen,loose stools,giddiness. Altered sensorium since 3 days. 

No relevant history in the past

Personal history:

Diet: mixed 

Appetite: normal

Sleep: Adequate 

Bowel and bladder: increased micturition(since 1week), normal bowel movements 

No addictions and allergies


GENERAL EXAMINATION:

Vitals:

BP 120/70 MMHG

PR 92 BPM

RR 28/MIN

GRBS 93 MG/DL

SpO2 100% ON 6L O2


 No pallor,No icterus, cyanosis, clubbing, lymphadenopathy. 


SYSTEMIC EXAMINATION ::

GIT

INSPECTION :

Abdomen - scaphoid 

Umbilicus - inverted 

Movements - all quadrants are equally moving with respiration

No scars and sinuses 

No visible peristalsis

No engorged veins.

PALPATION:

No local rise in temperature and no tenderness in all quadrants 

LIVER: no hepatomegly

SPLEEN- not enlarged 

KIDNEYS - bimanual palpable kidneys 

PERCUSSION :

no shifting dullness

AUSCULTATION :

Bowel sounds are heard and are normal

No bruit

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical

Type of respiration: thoraco abdominal.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- absent.

Vocal fremitus- normal on both sides.

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

Bilateral Airway entry - present. 

Decreased BS on the left side.

B/L crepts present in basal areas,wheeze present.

Cardiovascular system:

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Central Nervous system:

Higher motor functions- cannot be elicited 

Speech: Normal

Cranial nerve functions - cannot be elicited 

Sensory system- cannot be elicited 

Motor system Right  Left    

                    Power- UL 4/5  4/5

                                      LL 4/5  4/5 

                         Neck Normal 

                 Trunk muscles Normal  


          Tone- UL Normal Normal

                         LL Normal Normal 


          Reflexes- 

Superficial reflexes - Intact 

                             Plantar flexion  flexion

Deep tendon reflexes -

                           Biceps +   + 

                           Triceps +   +

                         Supinator +  +

                                Knee +   + 

                             Ankle +  + 

INVESTIGATIONS:  


29/4/23

 


1/5/23: 

  

2/5/23 








DIAGNOSIS : 

Altered sensorium secondary to  ? TB meningitis ? pyogenic meningitis 

 ?AKI ( Pre renal) resolved

?COPD(emphysematous)

? B/L pulmonary koch's with iron deficiency Anemia 

TREATMENT: 

1. IV FLUIDS NS @ 75 ml/hr

2. RT feed 

200 ml water 2 nd hrly

200 ml milk 4th hrly

3. Nebulization with budecort - 12 th hrly

Duolin -6 th hrly

Mucomist - 4 th hrly

4.SYP.GRILLINCTUS - 15 ml RT/TID

5.CPAP - Intermittently

6.Oxygen support to maintain spo2 88-94%

7.GRBS - 7 POINT PROFILE

8.Vitals monitoring 2nd hrly



Thanks to dr.tharun adn dr.deepthi interns posted in dept of general medicine for the daily soap notes and fever chart 


30/4/23

S

Stools passed 

No fever 


O

Pt is conscious, coherent and irritable

Speech is normal

No meningeal signs

GCS E 4 V4 M5

BP - 130/80 mm hg

PR - 92 bpm

SPO2: 96% ON 6L O2

RR: 28 cpm

CVS: S1S2 + , NO MURMURS

RS: BAE+ , B/L CREPTS + ,WHEEZE +

CNS: E4V4M5

                   Rt       lt

Tone UL     N        N

          LL     N        N


Power UL  4/5     4/5

            LL 4/5        4/5

       

Reflexes 

                 R              L

      B        +              +

      T         +              +

      S         +              +

      K          +             +

      A          +             +

      P          +              +



P/A: SOFT, NON TENDER

I/O:1800ml/800ml

GRBS: 108MG/DL



A

Altered sensorium secondary to ?sepsis ? TB meningitis

 ?AKI ( Pre renal) 

?Cor pulmonale 

? B/L pulmonary koch's with iron deficiency anemia



P

1. IV FLUIDS NS @ 75 ml/hr

2. RT feed 

200 ml water 2 nd hrly

200 ml milk 4th hrly

3. Nebulization with budecort - 12 th hrly

Duolin -6 th hrly

Mucomist - 4 th hrly

4.SYP.GRILLINCTUS - 15 ml RT/TID

5.CPAP - Intermittently

6.Oxygen support to maintain spo2 88-94%

7.GRBS - 7 POINT PROFILE

8.Vitals monitoring 2nd hrly. 



1/5/23

S

Stools passed 

No fever 


O

Pt is conscious, Not coherent to time,place, person and irritable

Speech is normal

No meningeal signs

GCS E 4 V4 M5

BP - 120/80 mm hg

PR - 84 bpm

SPO2: 92% ON RA

RR: 24 cpm

CVS: S1S2 + , NO MURMURS

RS: BAE+ ,WHEEZE(Expiratory) +

                   Rt       lt

Tone UL     N        N

          LL     N        N


Power UL  4/5     4/5

            LL 4/5        4/5

       

Reflexes 

                 R              L

      B        +              +

      T         +              +

      S         +              +

      K          +             +

      A          +             +

      P          +              +



P/A: SOFT, NON TENDER

I/O:2400ml/1050ml

GRBS: 124MG/DL



A

Altered sensorium secondary to  ? Pyogenic meningitis ? TB meningitis With AKI (pre renal) resolving 

?Cor pulmonale with COPD( emphysematous)

? B/L pulmonary koch's with iron deficiency anemia



P

1. IV FLUIDS NS @ 75 ml/hr

2. RT feed 

200 ml water 2 nd hrly

200 ml milk 4th hrly

3. Nebulization with budecort - 12 th hrly

Duolin -6 th hrly

Mucomist - 4 th hrly

4.SYP.GRILLINCTUS - 15 ml RT/TID

5.CPAP - Intermittently

6.Oxygen support to maintain spo2 88-94%

7.GRBS - 7 POINT PROFILE

8.Vitals monitoring 2nd hrly. 



2/5/23

S

No fever spikes


O

Pt is conscious, Coherent to person, Not coherent to time,place and irritable

Speech is normal

No meningeal signs

GCS E 4 V4 M6

BP - 130/70 mm hg

PR - 74 bpm

SPO2: 91% ON RA

RR: 22 cpm

CVS: S1S2 + , NO MURMURS

RS: BAE+ , B/L WHEEZE + R>L

                   Rt lt

Tone UL N N

          LL N N


Power UL 4/5 4/5

            LL 4/5 4/5

       

Reflexes 

                 R L

      B + +

      T + +

      S + +

      K + +

      A + +

      P + +



P/A: SOFT, NON TENDER

I/O:2400ml/1400ml

GRBS: 131MG/DL



A

Altered sensorium secondary to ? TB meningitis ? Pyogenic meningitis with AKI (pre renal) resolved with

? COPD( emphysematous)

? B/L pulmonary koch's with iron deficiency anemia



P

1. IV FLUIDS NS @ 75 ml/hr

2. RT feed 

200 ml water 2 nd hrly

200 ml milk 4th hrly 

3.Inj.MONOCEF 2g IV/BD

3. Inj.LASIX 40mg iv /OD 4.Nebulization with budecort - 12 th hrly

Duolin -6 th hrly

Mucomist - 4 th hrly

5.SYP.GRILINCTUS - 15 ml RT/TID

6.CPAP - Intermittently

7.Oxygen support to maintain spo2 88-92%

8.GRBS - 6th hrly.

9.Vitals monitoring 2nd hrly.  

10.Tab.RIFAMPICIN 150mg 

Tab.ISONIAZID 75MG 

Tab.PYRIZINAMIDE 400MG 

Tab.ETHAMBUTOL 275MG  

11.Tab.PYRIDOXINE 50MG PO/OD

3/5/23

S

No fever spikes


O

Pt is conscious, Coherent to time and person, Not coherent to place and slightly irritable

GCS E 4 V5 M6

BP - 120/80 mm hg

PR - 92 bpm

SPO2: 91% ON RA

RR: 22 cpm

CVS: S1S2 + , NO MURMURS

RS: BAE+ , Rt. IAA,ICA,IMA Expiratory rhonchi present 

                   Rt       lt

Tone UL     N        N

          LL     N        N


Power UL  4/5     4/5

            LL 4/5        4/5

       

Reflexes 

                 R              L

      B        +              +

      T         +              +

      S         +              +

      K          +             +

      A          +             +

      P          +              +



P/A: SOFT, NON TENDER

I/O:2900ml/1750ml

GRBS: 112MG/DL



A

Altered sensorium secondary to ? TB meningitis ? Pyogenic meningitis with AKI (pre renal) resolved with

 COPD( emphysematous)

B/L pulmonary koch's with iron deficiency anemia



P

1. IV FLUIDS NS @ 75 ml/hr

2. RT feed 

200 ml water 2 nd hrly

200 ml milk 4th hrly 

3.Inj.MONOCEF 2g IV/BD

4. Inj.LASIX 40mg iv /OD

5.Tab.RIFAMPICIN 150mg 

Tab.ISONIAZID 75MG 

Tab.PYRIZINAMIDE 400MG 

Tab.ETHAMBUTOL 275MG 

6.Nebulization with budecort - 12 th hrly

Duolin -6 th hrly

Mucomist - 4 th hrly

7.Oxygen support to maintain spo2 88-92%

8.GRBS - 6th hrly. 

9.Tab.PYRIDOXINE 50MG PO/OD

10.Vitals monitoring 2nd hrly. 

11.Chest physiotherapy 

ATT started from 2/5/23 


4/5/23

S
No fever spikes

O
Pt is conscious, Coherent and co operative 
GCS E 4 V5 M6
BP - 110/70mm hg
PR - 90 bpm
SPO2: 96% ON RA
RR: 20 cpm
CVS: S1S2 + , NO MURMURS
RS: BAE+ , NVBS heard
                   Rt lt
Tone UL N N
          LL N N

Power UL 4/5 4/5
            LL 4/5 4/5
       
Reflexes 
                 R L
      B + +
      T + +
      S + +
      K + +
      A + +
      P + +


P/A: SOFT, NON TENDER
I/O:3000/2150ml
GRBS: 92mg/dl 8am


A
Altered sensorium secondary to ? TB meningitis ? Pyogenic meningitis with AKI (pre renal) resolved with
 COPD( emphysematous)
B/L pulmonary koch's with iron deficiency anemia


P
1. IV FLUIDS NS @ 75 ml/hr
2. RT feed 
200 ml water 2 nd hrly
200 ml milk 4th hrly 
3.Inj.MONOCEF 2g IV/BD
4. Inj.LASIX 40mg iv /OD
5.Tab.RIFAMPICIN 150mg 
Tab.ISONIAZID 75MG 
Tab.PYRIZINAMIDE 400MG 
Tab.ETHAMBUTOL 275MG 
6.Nebulization with budecort - 12 th hrly
Duolin -6 th hrly
Mucomist - 4 th hrly
7.Oxygen support to maintain spo2 88-92%
8.GRBS - 6th hrly. 
9.Tab.PYRIDOXINE 40MG RT/OD
10.Vitals monitoring 2nd hrly. 
11.Chest physiotherapy
















The patient used ATT for only two months, and as their condition improved and symptoms subsided, they discontinued ATT on their own. The patient has been doing well as of 26-01-2024 and 15-04-2024. 
OUTCOME -   INADEQUATE USE OF MEDICATION BUT FULLY RECOVERED






 


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